**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, review of personnel files, interviews, and policy review, the facility failed to ensure care and services were provided in accordance with professional standards for 1 (Resident (R)77) of 3 closed records reviewed. Specifically, the facility failed to ensure nursing staff followed a resident's code status and physician order. The nursing staff performed Cardiopulmonary Resuscitation (CPR) on R77, even though the resident had selected Do Not Resuscitate (DNR). (Cross reference F835 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code status. The IJ is related to 42 CFR 483.25 - Quality of Care. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan that was accepted. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the IJ was removed on [DATE] at 5:30 PM. The facility remained out of compliance at F684 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F684, constituting substandard quality of care. Findings include: Review of the facility's undated policy titled, Advanced Directives indicated, Advance directives will be respected in accordance with state law and facility policy. Review of the facility's undated policy titled, Do Not Resuscitate Order indicated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Review of R77's electronic medical record (EMR) revealed R77 was admitted to the facility on [DATE], with diagnoses including but not limited to: Parkinson's disease and chronic atrial fibrillation. Review of R77's Documents tab in the EMR titled Emergency Medical Services Do Not Resuscitate Order, revealed that the resident has a terminal condition and that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest. The form was signed by R77 and the facility's Medical Director on [DATE]. Review of R77's Progress Notes in the EMR under the Progress Notes tab dated [DATE] at 1:30 AM, indicated, At 2226 [10:26 PM] Code Blue initiated. Resident observed cyanotic, weak pulse, no respirations by evidence of lack of diaphragmatic movement. CPR and EMS [Emergency Medical Services] initiated at that time. After 2 minutes Resident regained consciousness and respirations observed. Shortly thereafter EMS arrived. Review of employee files revealed Annual Employee In-Service which included a section on Advanced Directives, that indicated the information is easily accessible on paper medical records under the Advanced Directive Tab. The section also indicated, If a resident is found unresponsive (without pulse and respirations), call for help and follow CODE STATUS - located under Advanced Directives on chart. The section indicated that if a resident's code status is DNR Registered Nurse assess for s/s [signs and symptoms] of death and report to MD [Medical Doctor]. LPN6 was in-serviced on [DATE], LPN1 was in serviced on [DATE], and CNA2 was in-service on [DATE]. During an interview on [DATE] at 1:27 PM, R77's resident representative (RR) confirmed that the resident was transferred to the hospital on the evening of [DATE]. She stated that she was told by the hospital that CPR had been performed on the resident and she contacted the staff at the facility to let them know that R77's code status was DNR. During an interview with the Administrator and Director of Nursing (DON) on [DATE] at 2:28 PM, both stated that they were familiar with the situation. The Administrator confirmed that she was not aware of R77's code status until she arrived at the facility the morning of [DATE] at approximately 5:00 AM. She stated that upon her arrival, Certified Nursing Assistant (CNA)2 approached her. The Administrator was asked if it is the facility's policy for a CNA to initiate CPR. The Administrator stated that their policy states only nurses can initiate a code but added that after initiation any CPR qualified staff can assist. The DON confirmed that it is the policy of the facility that only nurses can initiate CPR. When asked what type of education is provided to the nursing staff to ensure all staff is aware, she stated, it is basic knowledge that nurses have to be the one to initiate CPR. During an interview with CNA2 on [DATE] at 2:55 PM, CNA2 stated that on the evening of [DATE], she was giving R77 a bed bath. CNA2 stated that she turned away to grab something, the resident had gone quiet and when she turned around, R77 was convulsing. CNA2 stated that she attempted to shake him and bring him back but after a few moments the resident fell unresponsive. CNA2 then stated that she ran to the hallway and called for help. She said that Licensed Practical Nurse (LPN)6 and LPN1 arrived at the resident's room. CNA2 stated that LPN6 stated she was going to get the crash cart. CNA2 stated that she felt no one was doing anything so she hopped on the bed and began CPR adding that she felt she was left to assist the resident alone. CNA2 confirmed that she was the only staff member to conduct CPR and she continued until a pulse could be found and the resident was responsive again. CNA2 was asked if she was aware of the R77's code status and she stated that she found out later from CNA3. In a subsequent interview with the DON on [DATE] at 3:51 PM, the DON provided documentation that an In-Service on the process for initiating a code and confirming a resident's code status was conducted on [DATE]. Per the documentation 14 staff members (seven nurses and seven CNAs) completed the in-service as of [DATE]. The Administrator was also present and was asked when she found out about the R77's code status. The Administrator stated that she found out later on [DATE], when R77's representative called to notify her that they had been advised by the hospital that CPR had been performed on the resident and wanted to clarify that R77's code status was DNR. The DON and Administrator were asked if they had done any other investigation or taken this concern to Quality Assurance and Performance Improvement (QAPI) and they both confirmed that they had not. During an interview via telephone on [DATE] at 6:32 PM, the Medical Director stated he was familiar with R77, who he recalled had diagnoses that included Parkinson's and atrial fibrillation. The Medical Director stated he was aware the resident was transferred to the hospital but was not aware that the resident coded or that CPR was performed. He added that he was aware of the resident having a DNR code status. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan which included the following: The resident's Electronic Medical Records have been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or resident's representative, that have elected a code status, the orders were updated to reflect the signed medical intervention. The necessary documentation has also been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE on [DATE] and placed at each nurse's station. The Administrator and Director of Nursing were educated by the CEO who is also a Social Worker, LNHA and Nurse on ensuring the resident is provided advanced directives upon admission, revised PRN and at a minimum of quarterly for any updates and changes they may elect. The Administrator and DON will educate the licensed nurses and certified nursing assistants to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed. The education will be completed for all licensed nurses and Certified Nursing Assistants by [DATE]. The licensed nurses and certified nursing assistants were educated on the facility's CPR/DNR policies to be completed [DATE]. They will be further instructed that a breach in a policy may result in a negative outcome, must have an investigation to include reporting to any state agency if warranted and reviewed with the monthly QAPI committee. The new licensed nurses and certified nursing assistants will be educated on the medical intervention status and location of the code status binder at each nurse's station during new hire orientation. The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents, or RR wishes for advanced directives, PRN, upon admission and at a minimum of quarterly. The Director of Nursing or designee will audit the Code Status Binders weekly for 4 weeks, monthly for 5 months or until 100% compliance is achieved. Any code called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action. The Director of Nursing will review their findings with the Administrator weekly for recommendations or follow up as indicated. The Administrator and/or Director of Nursing will report the finding of the weekly and monthly audit to the Monthly Quality Assessment Performance Improvement Committee for further recommendation as indicated. All areas will be completed by [DATE]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, job description review, staff interview and facility policy review, the facility Administrator failed to implement her job description to ensure the correct clinical operations related to resident's code status was followed. There is a potential for serious adverse outcomes because of the facility providing cardiopulmonary resuscitation (CPR) to a resident without confirming the code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes for 1 of 1 resident (Resident (R)77) reviewed. (Cross reference F684 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code status. The IJ is related to 42 CFR 483.70 - Administration. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan that was accepted. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the IJ was removed on [DATE] at 5:30 PM. The facility remained out of compliance at F835 at a lower scope and severity of D. Findings include: Review of the undated facility policy titled, Accidents and Incidents - Investigating and Reporting revealed, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Review of the Licensed Nursing Home Administrator job description dated [DATE], revealed the Administrator is responsible for the overall management of the facility. The Administrator . monitors and supports all operational, administrative, clinical, customer service . for the facility's programs and services. The Administrator . ensures the quality and appropriateness of resident/patient care meets or exceeds company and regulatory standards. Review of R77's Electronic Medical Record (EMR) revealed R77 was confirmed to have a Do Not Resuscitate (DNR) order. Review of the EMR Progress Notes tab revealed a Progress Note dated [DATE] at approximately 10:26 PM, R77 became unresponsive and received CPR by Certified Nurse Aide (CNA)2 with Licensed Practical Nurse (LPN)1 and LPN6 being aware. Neither the DON nor Administrator were aware of R77's code status until the resident's family member called to inform the facility. Review of Quality Assurance and Performance Improvement (QAPI) monthly meeting notes dated [DATE] through [DATE] revealed that Administration did not identify an adverse event which occurred on [DATE] in which R77's code status of DNR was not followed and CPR was performed by nursing staff. Administration failed to investigate this incident in order to correct the quality deficiency and ensure the incident does not recur. Administration implemented training of only 14 out of 47 nursing staff members and stated they meant to get to everyone but had not. The facility did not implement monitoring or other interventions. During an interview on [DATE] at 4:45 PM, the Administrator confirmed she was unaware of the resident's code status until she received a call from the resident's representative on [DATE]. She stated that she had not been contacted regarding the incident and only found out when she arrived around 5:00 AM on [DATE] the morning after the incident. The DON was also present during the interview and stated she was contacted the evening of the event. The DON added that she was working with the previous DON and was told to start inservice education. During an interview on [DATE] at 7:20 PM, the DON and Administrator in Training (AIT) both stated that this type of incident would normally be investigated and reviewed in QAPI and not addressing the incident was an oversight. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan which included the following: Unable to correct for resident 77 as the resident is no longer at the facility. The residents Electronic Medical Records has been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or residents representative that have elected Do Not Resuscitate has been updated. The necessary documentation has also been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE on [DATE] and placed at each nurse's station. The Administrator and Director of Nursing were educated by the CEO who is also a Social Worker, LNHA and Nurse on ensuring the resident is provided advanced directives upon admission, revised PRN and at a minimum of quarterly for any updates and changes they may elect. To include initiating an investigation if warranted. The investigation outcome if a breach of policy and procedure has been identified will include the corrective actions, staff training and monitoring of the deficient practice. The Administrator and DON will educate the licensed nurses to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed. The education will be completed for all licensed nurses by [DATE]. The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents, or RR wishes for advanced directives, PRN upon admission and at a minimum of quarterly. The Director of Nursing or designee will audit the Code Status Binders weekly for 4 weeks, monthly for 5 months or until 100% compliance is achieved. The Director of Nursing or designee will review their findings with the Administrator weekly for recommendations or follow up as indicated. Any code called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action. The Administrator and/or Director of Nursing will report the finding of the weekly and monthly audit to the Monthly Quality Assessment Performance Improvement Committee for further recommendation as indicated. All areas will be completed by [DATE]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, staff interview, and facility policy review, the facility failed to take an adverse event to Quality Assurance and Performance Improvement (QAPI) for corrective action, specifically, on [DATE], facility nursing staff administered cardiopulmonary resuscitation (CPR) to 1 of 1 resident (Resident (R)77) who had a Do Not Resuscitate (DNR) order in the electronic medical record (EMR). There is a potential for serious adverse outcomes because of the facility providing CPR to a resident without confirming code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes not being honored. (Cross reference F684 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code status. The IJ is related to 42 CFR 483.75 - Quality Assurance and Performance Improvement. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan that was accepted. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the IJ was removed on [DATE] at 5:30 PM. The facility remained out of compliance at F867 at a lower scope and severity of D. Findings include: Review of the undated facility policy titled Accidents and Incidents - Investigating and Reporting revealed, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of the undated facility policy titled Quality Assurance and Performance Improvement (QAPI) Plan revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems . objective of the QAPI plan . provide a means to identify and resolve present and potential negative outcomes related to resident care and services. Review of R77's Documents tab in the EMR titled Emergency Medical Services Do Not Resuscitate Order, revealed that the resident has a terminal condition and that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest. The form was signed by R77 and the facility's Medical Director on [DATE]. Review of R77's Progress Notes in the EMR under the Progress Notes tab dated [DATE] at 1:30 AM, indicated, At 2226 [10:26 PM] Code Blue initiated. Resident observed cyanotic, weak pulse, no respirations by evidence of lack of diaphragmatic movement. CPR and EMS [Emergency Medical Services] initiated at that time. After 2 minutes Resident regained consciousness and respirations observed. Shortly thereafter EMS arrived. Review of QAPI records dated [DATE] through [DATE], revealed the Quality Assessment and Assurance (QAA) committee was not aware of this high-risk, systemic issue, and was not monitoring facility practices related to accurate and consistent communication of residents' code status is being followed. During an interview on [DATE] at 7:20 PM, the Administrator stated the facility meets for QAPI monthly in which each department identifies issues and brings a Performance Improvement Project (PIP) to QAPI for compliance evaluation or additional recommendations. The Administrator stated QAPI reviews reportable incidents. The Administrator stated QAPI uses quality measures, survey results, and accidents/incidents. The Administrator stated the incident with R77 was not brought to the attention of QAPI. The DON and Administrator in Training (AIT) both stated that this type of incident would normally be investigated and reviewed in QAPI and not addressing the incident was an oversight. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan which included the following: Unable to correct for resident 77 as the resident is no longer at the facility. The residents Electronic Medical Records has been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or residents representative that have elected Do Not Resuscitate has been updated. The necessary documentation has also been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE on [DATE] and placed at each nurse's station. The Administrator and DON will educate the licensed nurses and certified nursing assistant to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed. The education will be completed for all licensed nurses and certified nursing assistants by [DATE]. The Administrator and Director of Nursing were educated by the CEO who is also a Social Worker, LNHA and Nurse on ensuring the resident is provided advanced directives upon admission, revised PRN and at a minimum of quarterly for any updates and changes they may elect. They were further instructed that a breach in a policy may result in a negative outcome must have an investigation to include reporting to any state agency if warranted reviewing serious concerns with the monthly QAPI committee. The licensed nurses and certified nursing assistants were educated on the facility's CPR/DNR policies to be completed [DATE]. The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents, or RR wishes for advanced directives, PRN upon admission and at a minimum of quarterly. The Director of Nursing or designee will audit the Code Status Binders weekly for 4 weeks, monthly for 5 months or until 100%compliance is achieved. The Director of Nursing or designee will review their findings with the Administrator weekly for recommendations or follow up as indicated. Any code status called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action. The Administrator and/or Director of Nursing will report the finding of the weekly and monthly audit to the Monthly Quality Assessment Performance Improvement Committee for further recommendation as indicated. All areas will be completed by [DATE]